New Patient Forms At East Tennessee Veterinary Ultrasound

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Phone(Required)

Secondary Phone

Email(Required)

How do you prefer to be contacted?(Required)

Phone

Text

Patient Information

Pet's Name(Required)

Pet's age(Required)

Please select one:(Required)

Dog

Cat

Breed(Required)

Color(Required)

Sex(Required)

Male

Male/Neutered

Female

Female/Spayed

Weight (if known)

Reason for visit:(Required)

Pet's Relevant Medical History(Required)

Current Diet including Brand names and any treats.(Required)

Pet Medication List

Please list all medications, supplements, and preventives your pet is currently taking. Provide the name, strength or concentration (if a suspension or transdermal), how much is given, route, and frequency of administration.

Feel free to take pictures and/or bring your pet’s medications to the appointment if there are any questions.

Name	Strength or Concentration	How Much Given	Route	Frequency
Pimobendan	5 mg	1 tablet	by mouth	every 12 hours
Methimazole	5 mg/ml suspension	1/2 ml	by mouth	every 12 hours
Simparica Trio	44–88 lb size	1 tablet	by mouth	once monthly

Current medications and supplements(Required)

Date of Appointment(Required)

Name of your regular veterinarian(Required)

Is there anything else you would like us to know about your pet?

Has your pet visited a veterinary practice or ER after your appointment was scheduled with us? if yes, please provide the name of the the practice so that we may contact them for your pet’s medical records.

If you would like to send us an image of your pet for the medical record, please upload it here.

Max. file size: 128 MB.

Payment Options
All payment is due at the time of service. For your convenience, we accept cash, all major credit cards, cashier’s checks and Care Credit Financing (6 month Financing Terms Only). We no longer accept personal checks. If assistance is needed with financial arrangements please contact us by phone or email. We offer a 2% cash discount.

Please note that you may need to fill out a captcha test before submitting the form. If you can’t submit the form, please scroll up to the top of the page and look for the captcha test.

CAPTCHA

New Client Registration

Patient Information

Pet Medication List

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